Advanced Network Opportunities for Surgical Tele-Robotics

Fall 2005 Internet2 Member Meeting Brett Harnett*

Assistant Professor, Research

Department of Surgery

*Contributors

• Brian Miller, PhD, Intuitive Surgical• Ken Wood, BS, Senior Systems Engineer, TATRC• Barry C. Herman, MSE, Researcher, WRAMC• Jean-Marc Gosselin, Haivision Systems, Inc.

– Peter Maag

Coming to a home near you?

Courtesy: Wired Magazine

In 1924, Radio News

envisioned a doctor examining a

remote patient via the electromagnetic

spectrum.

Having Vision

A Paradigm Chasm

“It has become appallingly obvious that our technology has exceeded

our humanity. ”

~Albert Einstein

Think Creatively

Even if you are a doc

• Telemedicine: application of telecommunications in medical care

• Telesurgery: remotely performed surgery through combined use of telecommunications and a surgical robot

Nomenclature

How Stuff Will Work?

Operation Lindbergh

8Mbps 155msec ATM network + Zeus TSNew York - Strausbourg

Laparoscopic cholecystectomy

Sept 7, 2001

The daVinci

Images courtesy of Intuitive Surgical

Traditional vs. Robotic

Diagrams courtesy of Intuitive Surgical

The message:

“Raising The Bar: Improving Technology in the Continuum of Care”.

• Key Partners• Intuitive Surgical (medical robots)• Walter Reed Army Medical Center• Johns Hopkins University• University of Cincinnati

ATA Demonstration

Courtesy: HaiVision

PublicInternet

PublicInternet

Sunnyvale - Veterans Hospital

Denver - ATA Show

Denver ISPPriority Networks

Sunnyvale ISP NextWeb

hai560

hai560

ATA Demo April 2005

- No VLAN

- No QoS

1.8 Mbps

10 Mbps 8 Mbps

1.8 Mbps

Courtesy: HaiVision

Network Configuration

• hai560 codec on show floor at ATA Denver

• hai560 codec in Operating Room at Sunnyvale Veteran’s Hospital, CA

• Local ISPS in Denver and Sunnyvale connected over public Internet

ATA Configuration

Courtesy: HaiVision

• Critical Interaction Attributes• Low latency for hand-eye coordination

– typically 40ms network and less than 120ms video encoding

• Best video quality – full resolution DVD quality

• Resiliency to network jitter and lost packets

• High reliability hardware and software – no resets, reboots, etc.

Critical Interaction Attributes

Courtesy: HaiVision

Surgical Performance

Mean Times: Suturing

Mean Errors: Suturing

Real Time Internet Connections:Implications for Decision Making in Laparoscopy

• Purpose:– To determine if low bandwidth Internet connection can provide

adequate image quality to support remote surgical consultation

• Method:– Lap CCY in Ecuador & DR remotely proctored via Internet connection– Local and remote images were screen grabbed and placed in a web-

based tool

• Result:– First to identify critical laparoscopic anatomy via an Internet connection– Successful proctoring of 6 lap CCY via an Internet connection– In the web-based tool, remote/local images indistinguishable

• Conclusion:– Low bandwidth, Internet-based telemedicine can support intraoperative

consultation in laparoscopic surgery.

Broderick et al. Ann Surg 234(2): 165-71; 2001

Battlefield Extraction

Credit: USAMRMC / TATRC

We must focus…

Telecom Issues

Telemedicine Telesurgery

Security Encrypted Encrypted VPN

Protocol IP IP

Bandwidth Kbps Mbps

Latency Async & Sync Sync - Lowest

QoS Low High

Availability Widespread Limited

Cost Low Prohibitive

Primary Issues

• Bandwidth - How much is really needed?• Scalability – To what extent?• QoS – Surgical grade network with prioritization• Inter-Networking - Peering points, tariff

agreements• Standards - Ensuring interoperability and cost

reduction• Security – Privacy, loitering, DoS, etc.• Military requirements – on the battlefield• NASA – Orbital and lunar, not interplanetary

Metrics

• Performance– Latency– Jitter– Packet Loss

• From Commerce Internet (CI) to CI with QoS• From CI to Cincinnati Bell LAN Advantage• From CI to Internet2

SYNCHRONOUS transfer; UDP

Internet2 Can Do

• Virtual Reality

• Telepresence

• Avatars

• Reverse Sensory Underload

Challenges

• Bandwidth

• Scalability

• QoS

• Haptics & visual fidelity

• Interoperability

• Risk analysis/liability

• Operationally - contingency plans when…

When Things Go Wrong

In a Nutshell

• Standardization efforts should continue, with emphasis on interoperability standards of network protocols and interfaces for telerobotic surgery. These would be validated/benchmarked via demonstrations, possibly between institutions that are part of an organized standards collaboratory.

• The network could extend between robots, robots and other O.R. equipment, interfaces with clinical and imaging information systems, onwards to possible function on Internet2 to allow surgeons to train, collaborate and tele-mentor cases. This could eventually be used for telesurgical applications both within and outside of a given hospital.

Mission Critical

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Brett HarnettResearch Assistant ProfessorUniversity of CincinnatiCenter for Surgical Innovation

brett.harnett@uc.edu

(Translation: Thank you!)